Disclosure Seshadri Raju, M.D. I disclose the following financial relationship(s): •Ownership Interest: Veniti Stock and Device Company
Jul 03, 2015
Disclosure Seshadri Raju, M.D.
I disclose the following financial relationship(s):
•Ownership Interest: Veniti Stock and Device Company
Non-Thrombotic Iliac Vein Lesions: Permissive Role in CVD
Pathogenicity
Seshadri Raju MD.FACS.
The Rane Center
Flowood. MS>
First description of Iliac vein compression 1908
Popularized by May and Thurner in 1957 Left side dominance noted.
Known as Cockett syndrome in UK (1967) His patients mostly young women involving left leg
“Classic lesion” beneath right iliac artery crossing. Traumatic, not thrombotic; congenital in some.
Not merely compression, but intraluminal webs also (NIVL)
NIVL
Diagnostic sensitivity of venography:≈50%
In 30% of NIVL cases venograms appear “normal” and the lesion is well hidden
IVUS IN NIVL WITH WEB
IVUS can measure area unlike in venography. 64 sq. mm in this case.
In adults CIV should measure ≥ 175 sq mm
With IVUS, NIVL occurs on both sides, both sexes and in all age groups.
Proximal and distal NIVL
Sensitivity of Diagnostic Techniques for Obstruction (IVUS Positive)
• Ascending Venography 245/386 63% • Collaterals Present 165/382 43% • Femoral V Pr > 3mmHG 20/133 15% (over opposite limb) • Exercise Fem V Pr 92/175 53% • Arm/Foot resting Diff 37/228 15% • Foot Pr (Reactive Hyper) 125/224 56% • Doppler- No Phasicity 250/423 59% • Diagnostic IVUS is recommended even if above
tests are negative.
How common is obstruction in primary reflux?
• May-Thurner type iliac vein lesions are common in the normal population. Recent MR studies show such lesions in ≈60% of the asymptomatic general population in silent form.
• IVUS positive obstructive lesions of the iliac vein are frequently present (>90%) in CEAP class 3 and higher “primary” reflux cases!
• Why?
Iliac Vein obstruction is a permissive pathology
J Vasc Surg 44: 136-143; 2006
• Iliac vein obstructive lesions are “permissive” ie. they remain silent till an additional or secondary insult precipitates symptoms.
• Therefore, there is “High Prevalence” in symptomatic patients.
• Permissive pathologies are ubiquitous in human diseases. Many examples. Classic PFO
• Rx of permissive pathology usually results in clinical relief. Repair of secondary insult is required only infrequently.
Examples of other permissive pathologies
Obesity & Diabetes
Diabetes & Neuropathy
Carotid stenosis & TIA
Ureteric reflux & pyelonephritis
PFO & Stroke
Esophageal reflux & Asthma
Barrett’s esophagus and cancer
Helicobacter and gastric ulcer
Stenting NIVL is curative even when associated reflux is uncorrected suggesting that
reflux may be a secondary insult.
Ulcer
Secondary Insults that may precipitate symptoms in the presence of a silent
iliac vein lesion. • Trauma
• Infection
• Reflux (incidence↑ age)
• DVT
• joint surgery
• Seated orthostasis and
Poor calf pump (elderly)
• Obesity
• Edematogenic meds.
• Postmenopausal hormonal changes
• Lymphatic damage from vein disease itself or from, cancer, radiation, chemo, surgery.
Trauma Cellulitis Joint Replacement
Postthrombotic focal stenosis Not readily apparent on venogram
Trabeculum
Postthrombotic lesions are also permissive
Remote DVT decades ago remaining silent till secondary insult precipitates symptoms.
IVUS/ILIAC VEIN STENTING: INDICATIONS
• Based on clinical considerations, not radiologic findings howsoever bad
• Pain, Swelling, Dermatitis/ulcer ie. advanced manifestations of CVI; Recurrent cellulitis is another indication.
• Failed conservative therapy.
“Venous Hypertension” syndrome: Orthostatic pain only symptom. Limb with normal appearance.
Leg swelling in old ladies is often neglected. NIVL or PTS lesions are often present. Leg swelling retards mobility
and self care. Bilateral lesions occur in ≈20% .
In the younger patient, swelling is a quality of life issue. Painful leg swelling is highly
symptomatic.
“Classic” clinical signs of lymphedema are unreliable; venous swelling can mimic them. Do IVUS!
30% of CVD cases will have secondary lymphedema due to use overload! Probably the commonest cause
of lymphedema in US
Why do iliac vein stents work? • Iliac veins are major outflow tracts and the
importance and incidence of obstruction has been underestimated due to diagnostic difficulties.
• Advanced CVI is multifocal pathology, comprising both obstruction and reflux in about 60%. (Pure obstruction in about 40%).
• CVI uniquely responds to partial correction ie. correction of either pathology often results in clinical relief.
Unexpected Major Role for Venous Stenting in Deep Reflux Disease:
Symptom Relief with Partial Correction of Pathology. Raju S, Darcey RL, Neglén P
J Vasc Surg 51: 401-408; 2010.
• We stented iliac vein obstruction in combined obstruction/reflux in 528 limbs with plans for reflux repair later.
• Clinical relief from initial stenting was unexpectedly good and correction of the remaining reflux was not necessary.
Stent Outcome is good even if reflux is present and uncorrected
n=528 Limbs Reflux Distribution
Deep Reflux only 32%
Deep and Suprfl 68%
Perforator 21%*
*(all with Deep or D/S Reflux)
_____________________
Axial Reflux 42%
Reflux Segmnt Score**
Mean 2.9 ± 1.5 **1 each for Fem, Prof, Pop, Prox
GSV, Distal GSV, SSV and Perf.
Maximum Possible 7
_________________Reflux segment Score of >3 in 58%
REFLUX PARAMETERS
Pre-Stent Post-Stent
Test median (r) N median (r) N P
% Drop 62 (0-100) 403 64 (19-100) 134 0.37 VFT 16 (1-123) 400 18 (2-160) 132 0.41 VFI90 2.8 (0-16.6) 473 2.2 (0-14.1) 209 0.02* *significant
Reflux was unchanged or improved but did not worsen
after stenting.
STENT PATENCY J Vasc Surg 46: 979-990, 2007
0 6 12 18 24 30 36 42 48 54 60 66 720
10
20
30
40
50
60
70
80
90
100
Primary
Assisted-primary
Secondary
603 383 290 243 195 165 139 114 88 69 53 34603 381 287 242 195 165 139 114 88 69 53 34603 373 267 218 176 143 113 90 68 52 39 24
Months
Pa
ten
cy
Ra
tes
(%
)
93%89%
67%
0 6 12 18 24 30 36 42 48 54 600
10
20
30
40
50
60
70
80
90
100
148 86 70 55 46 37 31 24 20 15
Months
Lim
bs
wit
h H
ea
led
Ulc
ers
(%
)Ulcer Healing
58%
0 6 12 18 24 30 36 42 48 54 600
20
40
60
80
100
Pain - Complete relief
Pain - Complete and partial relief (Reduction 3 on VAS)
Swelling - Complete relief
Swelling - Complete and partial relief (improvement 1 degree)
Months
Cu
mu
lati
ve
Sy
mp
tom
Re
lie
f (%
) Relief of Pain and Swelling; n=982 limbs
74%
62%
65%
32%
[SEM <10%]
QOL (CIVIQ) improved in every category
Pre-Stent Post-Stent P
n=395 n=179
Pain 3 (1-5) 3 (1-5) <.0001*
Work 4 (1-5) 3 (1-5) <.0001*
Sleep 3 (1-5) 2 (1-5) <.0003*
Social 3.25 (1-5) 2.625 (1-5) <.0001*
Morale 2.778 (1-5) 2.556 (.9-5) <.0029*
Total 66 (20-100) 53 (20-100) <.0001*
*significant
UMC VALVULOPLASTY PROGRAM ’80s
0
50
100
150
200
250
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Nu
mb
er
of
inte
rve
nti
on
s
Valve repair Venous Stentings
END